Definitive chemoradiotherapy with docetaxel, cisplatin, and 5-fluorouracil (DCF-R) for advanced cervical esophageal cancer

Abstract

Background

Recently, definitive chemoradiotherapy (dCRT) has become one of the essential treatment strategies for esophageal squamous cell carcinoma (ESCC) and has been especially gaining prevalence for cervical ESCC to preserve the larynx. Our department recently introduced dCRT concomitant with docetaxel, cisplatin, and 5-fluorouracil (DCF-R) for treating advanced cervical ESCC. This study aims to assess the safety and outcomes of DCF-R in patients with advanced cervical ESCC.

Methods

We retrospectively assessed 11 patients with advanced cervical ESCC (clinical stage: II–IV, including T4b and/or M1 lymph node) who received DCF-R as the first-line treatment between December 2010 and February 2015.

Results

Our patient cohort comprised 8 males and 3 females (median age 68 years; range 54–76 years). The pretreatment clinical stage included stage II (1), stage III (7), and stage IV (3) cases [including 3 patients with T4b (2 trachea and 1 thyroid) and 3 patients with M1 lymph node]. We attained complete response (CR) in 10 patients and stable disease in 1 patient. Of 10 patients with CR, 5 experienced recurrence and 5 continued exhibiting CR. Furthermore, grade 3 or more adverse events included leucopenia (91%), neutropenia (91%), febrile neutropenia (45%), and pharyngeal pain (55%). While the 2-year overall survival rate was 72%, the 2-year recurrent-free survival rate was 64%, respectively.

Conclusions

DCF-R treatment for advanced cervical esophageal cancer could be completed by the careful administration; although a strong blood toxicity might occur, this treatment may provide the chance to obtain favorable prognosis with larynx preservation.

Effects of arsenic methylation and metabolism on the changes of arsenic-related skin lesions

Abstract

Little was known about the arsenic metabolism and arsenic methylation associated with the changes of skin lesions after reducing the arsenic in drinking water (WAs). Therefore, urinary concentrations and proportions of arsenic species were determined for recovery (RC), improvement (IC), persistent (PE), aggravation (AC), new incidence (NC), and no sign (HC) groups based on the changes of skin lesions between before (in 2004) and after (in 2017) WAs reduction. The results indicate that the urinary concentrations of inorganic arsenic (iAs), monomethylarsonic acid (MMA), dimethylarsinic acid (DMA), and total arsenic (TAs) were much higher for RC and IC groups than for the other groups in 2004, while these values varied slightly among the groups in 2017. The urinary %iAs of all the groups was significantly decreased after WAs reduction. In contrast, the urinary %DMA of RC, IC, AC, and NC groups was increased. From 2004 to 2017, the PE and HC groups had lower decrease rate of %iAs and %MMA, and increase rate of %DMA, primary methylation index (PMI), and secondary methylation index (SMI) after WAs reduction. The adjusted odd ratios (ORs) showed that the RC, IC, AC, and NC groups were positively related with %iAs and %MMA and were negatively correlated with %DMA, PMI, and SMI before WAs reduction. It can be concluded that higher urinary %iAs and %MMA before WAs reduction increased the probability of skin lesions recovery and improvement, and the risks of skin lesions aggravation and incidence. Higher increase rate of urinary %DMA was positively associated with of skin lesions recovery and improvement. Moreover, higher urinary %iAs and %MMA or lower increase rate of urinary %DMA might increase the risk of skin lesions aggravation.

Time Course of Cerebral Perfusion Changes in Children with Migraine with Aura Mimicking Stroke [PEDIATRICS]

SUMMARY:

Hemiplegic migraine is a common cause of acute brain attack in pediatrics. MR imaging sequences useful in differentiating hemiplegic migraine from other entities include arterial spin-labeling, SWI, MRA, and DWI. There has been limited exploration on the simultaneous use of these sequences in pediatrics. We present 12 pediatric patients with acute hemiplegic migraine or migraine with aura who underwent MR imaging within 12 hours of symptom onset. Quantitative and qualitative analyses were performed on arterial spin-labeling; and qualitative analysis, on SWI and MRA sequences. All 12 patients had normal DWI and abnormal arterial spin-labeling findings. Furthermore, we observed a more rapid transition from hypoperfusion to rebound hyperperfusion in 3 patients compared with prior reports. These findings support the use of multimodal MR imaging to distinguish migraine with aura from stroke and the simultaneous use of these MR imaging sequences to improve understanding of perfusion changes during migraine with aura.

Prognostic Implications of Gadolinium Enhancement of Skull Base Chordomas [HEAD & NECK]

BACKGROUND AND PURPOSE:

Skull base chordomas often demonstrate variable MR imaging characteristics, and there has been limited prior research investigating the potential clinical relevance of this variability. The purpose of this retrospective study was to assess the prognostic implications of signal intensity on standard imaging techniques for the biologic behavior of skull base chordomas.

MATERIALS AND METHODS:

Medical records were retrospectively reviewed for 22 patients with pathologically confirmed skull base chordomas. Clinical data were recorded, including the degree of surgical resection, the presence or absence of radiation therapy, and time to progression/recurrence of the tumor or time without progression/recurrence of the tumor following initial treatment. Pretreatment imaging was reviewed for the presence or absence of enhancement and the T2 signal characteristics. Tumor-to-brain stem signal intensity ratios on T2, precontrast T1, and postcontrast T1 spin-echo sequences were also calculated. Statistical analysis was then performed to assess correlations between imaging characteristics and tumor progression/recurrence.

RESULTS:

Progression/recurrence of skull base chordomas was seen following surgical resection in 11 of 14 (78.6%) patients with enhancing tumors and in zero of 8 patients with nonenhancing tumors. There was a statistically significant correlation between skull base chordoma enhancement and subsequent tumor progression/recurrence (P < .001), which remained significant after controlling for differences in treatment strategy (P < .001). There was also a correlation between postcontrast T1 signal intensity (as measured by postcontrast T1 tumor-to-brain stem signal intensity ratios) and recurrence/progression (P = .02). While T2 signal intensity was higher in patients without tumor progression (median tumor-to-brain stem signal intensity ratios on T2 = 2.27) than in those with progression (median tumor-to-brain stem signal intensity ratios on T2 = 1.78), this association was not significant (P = .12).

CONCLUSIONS:

Enhancement of skull base chordomas is a risk factor for tumor progression/recurrence following surgical resection.

Zonally Magnified Oblique Multislice and Non-Zonally Magnified Oblique Multislice DWI of the Cervical Spinal Cord [SPINE]

BACKGROUND AND PURPOSE:

The zonally magnified oblique multislice EPI (ZOOM-EPI) diffusion-weighted sequence has been visually shown to provide superior MR diffusion image quality compared with the full-FOV single-shot EPI sequence (non-ZOOM-EPI) in the adult cervical spinal cord. The purpose of this study was to examine the diffusion tensor imaging indices in the normal human cervical spinal cord between ZOOMED and non-ZOOMED DTI acquisitions and determine whether DTI values are comparable between direct and indirect age-matched groups.

MATERIALS AND METHODS:

Fifty-four subjects 23–58 years of age (9 direct age-matched and 45 indirect age-matched) were scanned using a 1.5T scanner. Diffusion tensor indices including fractional anisotropy, mean diffusivity, axial diffusivity, and radial diffusivity were generated from the DTI dataset. These DTI values were calculated for both ZOOM and non-ZOOM acquisitions and compared at each intervertebral disc level. The variability of the DTI values for ZOOM and non-ZOOM sequences was measured using a coefficient of variation within direct and indirect age-matched controls.

RESULTS:

The mean diffusivity, axial diffusivity, and radial diffusivity values obtained along the cervical spinal cord in the age-matched controls showed a significant decrease using the ZOOM sequence (P = .05, P = .002, and P < .001). Mean fractional anisotropy showed a significant increase (P = .04) using the ZOOM sequence. The indirect age-matched controls showed a statistically significant increase in fractional anisotropy (P = .03) and a decrease in mean diffusivity (P = .002), axial diffusivity (P < .001), and radial diffusivity (P = .002) using the ZOOM sequence. Less variability has been shown in DTI using the ZOOM sequence compared with the non-ZOOM sequence in both direct and indirect age groups. The ZOOM sequence exhibited higher SNR (SNR_ZOOM = 22.84 ± 7.59) compared with the non-ZOOM sequence (SNR_non-ZOOM = 19.7 ± 7.05). However, when we used a 2-tailed t test assuming unequal variances, the ZOOM sequence did not demonstrate a statistically significant increase.

CONCLUSIONS:

ZOOM DTI acquisition methods provide superior image quality and precision over non-ZOOM techniques and are recommended over conventional full-FOV single-shot EPI DTI for clinical applications in cervical spinal cord imaging.

Detection and Characteristics of Temporal Encephaloceles in Patients with Refractory Epilepsy [ADULT BRAIN]

BACKGROUND AND PURPOSE:

Temporal encephaloceles are increasingly visualized during neuroimaging assessment of individuals with refractory temporal lobe epilepsy, and their identification could indicate an intracranial abnormality that may be related to a potential seizure focus. Careful review by an experienced neuroradiologist may yield improved detection of TEs, and other clinical, neurophysiologic, and radiologic findings may predict their presence.

MATERIALS AND METHODS:

Data were reviewed retrospectively in patients at our institution who were presented at a multidisciplinary conference for refractory epilepsy between January 1, 2010, and December 31, 2016. Clinical, neurophysiologic, and imaging data were collected. An expert neuroradiologist reviewed the latest MR imaging of the brain in patients for whom one was available, noting the presence or absence of temporal encephaloceles as well as other associated imaging characteristics.

RESULTS:

A total of 434 patients were reviewed, 16 of whom were excluded due to unavailable or poor-quality MR imaging. Seven patients had temporal encephaloceles reported on initial imaging, while 52 patients had temporal encephaloceles identified on expert review. MR imaging findings were more often initially normal in patients with temporal encephaloceles (P < .001), and detection of temporal encephaloceles was increased in patients in whom 3T MR imaging was performed (P < .001), the T2 sampling perfection with application-optimized contrasts by using different flip angle evolutions sequence was used (P < .001), or the presence of radiologic findings suggestive of idiopathic intracranial hypertension was noted. Seizure onset by scalp electroencephalogram among patients with temporal encephaloceles was significantly more likely to be temporal compared with patients without temporal encephaloceles (P < .001). A significant correlation between intracranial electroencephalogram seizure onset and patients with temporal encephaloceles compared with patients without temporal encephaloceles was not observed, though there was a trend toward temporal-onset seizures in patients with temporal encephaloceles (P = .06).

CONCLUSIONS:

Careful review of MR imaging in patients with refractory temporal lobe epilepsy by a board-certified neuroradiologist with special attention paid to a high-resolution T2 sequence can increase the detection of subtle temporal encephaloceles, and certain clinical and neurophysiologic findings should raise the suspicion for their presence.

Contextual Radiology Reporting: A New Approach to Neuroradiology Structured Templates [PRACTICE PERSPECTIVES]

SUMMARY:

Structured reporting has many advantages over conventional narrative reporting and has been advocated for standard usage by radiologic societies and literature. Traditional structured reports though are often not tailored to the appropriate clinical situation, are generic, and can be overly constraining. Contextual reporting is an alternative method of structured reporting that is specifically related to the disease or examination indication. Herein, we create a library of 50 contextual structured reports for neuroradiologists and emphasize their clinical value over noncontextual structured reporting. These templates are located in the On-line Appendix, and a downloadable PowerScribe 360 file may be accessed at https://drive.google.com/open?id=1AlPUmfAXPzjkMFcHf7vGKF4Q-vIdpflT.

MR Imaging Features of Anaplastic Pleomorphic Xanthoastrocytoma Mimicking High-Grade Astrocytoma [ADULT BRAIN]

BACKGROUND AND PURPOSE:

Anaplastic pleomorphic xanthoastrocytoma, which has been recently defined as a distinct entity in the 2016 World Health Organization classification, may exhibit aggressive clinical behavior and relatively worse prognosis than pleomorphic xanthoastrocytoma. This study aimed to investigate whether there were any differences in MR imaging characteristics between these 2 tumors.

MATERIALS AND METHODS:

This retrospective study included 9 patients with anaplastic pleomorphic xanthoastrocytoma and 10 patients with pleomorphic xanthoastrocytoma who underwent MR imaging before an operation. DWI was performed in 17 patients (8 with anaplastic pleomorphic xanthoastrocytoma, 9 with pleomorphic xanthoastrocytoma); and DSC-PWI, in 9 patients (5 with anaplastic pleomorphic xanthoastrocytoma, 4 with pleomorphic xanthoastrocytoma). Demographics, conventional imaging characteristics (location, size, cystic degeneration, enhancement, peritumoral edema, and leptomeningeal contact), minimum relative ADC ratio, and maximum relative CBV ratio were evaluated between the anaplastic pleomorphic xanthoastrocytoma and pleomorphic xanthoastrocytoma groups.

RESULTS:

Anaplastic pleomorphic xanthoastrocytoma was more likely to demonstrate high-grade features than pleomorphic xanthoastrocytoma, including greater maximum tumor diameter (4.7 ± 0.6 cm versus 3.1 ± 1.1 cm, P = .001), more frequent heterogeneous contrast enhancement of solid portions (88.9% versus 20.0%, P = .01), more obvious peritumoral edema (2.3 ± 0.9 cm versus 1.0 ± 0.9 cm, P = .008), lower minimum relative ADC on DWI (1.0 ± 0.2 versus 1.5 ± 0.4, P = .008), and higher maximum relative CBV on DSC-PWI (2.6 ± 0.8 versus 1.6 ± 0.2, P = .036).

CONCLUSIONS:

Anaplastic pleomorphic xanthoastrocytomas often have more aggressive MR imaging features mimicking high-grade astrocytomas than pleomorphic xanthoastrocytomas. DWI and DSC-PWI might be useful in the characterization and differentiation of anaplastic pleomorphic xanthoastrocytoma and pleomorphic xanthoastrocytoma.

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Cutaneous squamous cell carcinoma progression during imiquimod treatment

To the Editor: We read with interest the paper by Que SKT et al regarding the management of cutaneous squamous cell carcinoma (cSCC)1 and the remarkable discussion about the field treatment with topical chemotherapy agents. Imiquimod is an immune response modifier that activates immune cells via toll-like receptor 7, initiating a cascade leading to the induction of cytokines, such as interferon alfa, interferon gamma, and interleukin 12, which promote a T helper 1 (TH1) immune response.2 The use of imiquimod for the treatment of invasive cSCC is not approved by the European Medicines Agency or Food and Drug Administration, but few reports have described its success in elderly patients and when other treatments and surgery are contraindicated.

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Reply to: “Prognostic significance of tumor budding in cutaneous squamous cell carcinoma”

To the Editor: We would like to thank Kanitakis and Karayannopoulou1 for highlighting that a key point of our article on the prognostic significance of tumor budding in cutaneous squamous cell carcinoma (cSCC) is the assessment method.2 We fully agree that a consensus method is needed because tumor budding is increasingly being recognized as a prognostic factor in several cancers.

Association of 25-hydroxyvitamin D levels and cutaneous melanoma: A nested case-control study of the Women's Health Initiative Observation Study

To the Editor: Exposure to ultraviolet radiation is an important risk factor for melanoma but is also the principal means by which the body synthesizes vitamin D in the skin. Prior studies on the association between 25-OH-D levels and melanoma occurrence and prognosis have shown conflicting results.1,2

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